Assignment #4

SW 316 Resource Referral Assignment

(intake assessment)
The Intake Assessment paper should be formally written and typed, with multi-dimensional analysis
considering all variables on the Intake Outline attached to this assignment. Students should include as much
information from the actual guest speaker as possible and are encouraged to critically think about this case
situation.
As students develop the assignment, they are to be aware of how their own values may affect the way they
view and assess the individuals situation, values, dreams, goals and desired outcomes.
This Intake assessment should be approximately 3-4 pages in length. This should be written like an
agency assessment, not as an APA-style academic paper. The attached information should help guide
your thinking. Students must provide a resource list with a minimum of five resources. Students will need to
call agencies and inquire about eligibility. Identify these in the recommendations section of the write-up.
The assessment should follow the format on the Assessment Outline attached. It is important to clarify the
experiences of individual(s), their relationships, problems and issues according to how they perceive them and
according to the students interpretation of information that is provided and observed. Assessment is to be
consistent with social work values and a strengths-based process should be employed.
In the following Intake Assessment Guide, it is important to note that many of the items described as
examples may not be addressed in the actual interview or that the information is addressed however, there may
be no concerns in that particular area of functioning. Students maintain a responsibility to organize and report
in the format prescribed below, and to clarify areas even where there is no identified impairment or areas
where no information was presented. It is important to convey to the reader that either these areas were not
discussed in the interview and/or they were not areas of concern. This concept will be discussed in class and
can be further clarified by the professor.

The Intake Assessment Guide

I. The Presenting Problem
a) The clients age (if known), gender and ethnicity of client, reason for referral, referral source,
client/family perception of needs.
II. Summary of Clinical Screening and Assessment Results
A. Emotional /Behavioral and Mental Status
b) Mood/Affect Appropriate, depressed, anxious, manic, angry, flat, other. (All categories Refer to at
least the last thirty days and can be multidimensional) example; Sarah expressed she struggled with
feelings of depression twice this month, but went on to indicate that her mood is often appropriate.
c) Attitude Cooperative, guarded, oppositional, other.
d) Appearance Appropriate to the season/setting, disheveled, poor hygiene, weight concerns,
intoxicated/high, other.
e) Self-Regulation No concerns, change in (energy, appetite, eating, sleep) sensory, nightmares,
flashbacks, other.
f) History of emotional problems None, mood, depression, anger, psychosis, other.
g) Risk to self none, history of suicidal thought, gestures and attempts, barriers to intent, desire to die,
access to weapons, definition of a plan.

h) Risk to others None, animals, people, property, family only, certain groups of people.
i) History of behavioral problems none, violence, disruptive, aggressive, theft, sexual, impulsive,
other.
j) Current behavioral problems none, violence, disruptive, aggressive, theft, sexual, impulsive, other.
k) Family history of emotional/behavioral problems none, children, mother, father, siblings,
significant other, other.
B. Substance Use and History of Behavioral Health Services
a) Family history of substance abuse, use, and dependence none, mother, father, siblings, children,
significant other, other,
b) Addictive behaviors none, substance use, food, gambling, substance dependence, sexual, other.
c) Problems associated with addictive behaviors none, financial, legal, family, physical health, work,
school, friends, emotional health, spiritual, other.
d) History of addictions Current Use substance or activity, age at first use, route (oral, smoke, inject,
inhale), age at heaviest use, frequency at heaviest use, frequency of use in the last six months, last
use.
e) Previous/current behavioral health services or treatment level of care, where
(agency/facility/therapist), level of care (outpatient, home-based, intensive outpatient, inpatient,
partial hospitalization, residential treatment, community based services etc.), reasons for previous
treatment (mental health, substance abuse, sexual assault/victimization/perpetration, co-occurring,
other).
C. Social Screening
a) Who resides in the home children, adults, friends, roommates, ages.
b) Dependents/guardianship parent, ward of state, ward of court, emancipated minor, pregnant, other.
c) Current family circumstance stable, custody issues, chaotic, violence, loss, incarceration, risk for
abuse/neglect, other.
d) Family relationships client positive/negative impact on family, family positive/negative impact on
family.
e) Quality of interaction/attachment (children under age 18) Secure, insecure, conflicted, distressed,
hostile, other.
f) Childhood history no concerns, foster care, abuse/neglect, domestic violence, Divorce, other.
g) History of Traumatic Events h) Environment safe, unsafe, homeless, other.
i) External Support no problems, peer groups, inadequate support, high risk, other.
j) Recreation/play/leisure no concerns, isolated, age inappropriate, high risk, lacking, other.
k) Spiritual cultural positive impact on presenting problem, negative impact on presenting problem,
no impact on presenting concerns, other.
l) Sexual history no concerns, perpetration, high risk, victim/assault, abuse, early practice, other.
m)Employment/Vocational issues no concerns, seeking job, needs training, other.
n) Educational issues none, academic concerns, special education, behavioral concerns, truancy,
expelled/suspended, dropped out, other.
o) Financial issues financial concerns, no financial concerns, other.
p) Legal issues none, probation, parole, incarcerated, services court ordered, history of legal
involvement, other.
q) Military service history none, no impact on presenting problem, related to services/presenting
issue, other.

D. Developmental (required for children and adolescents only)

a) Birth history no concerns, history of loss, unplanned, pregnancy/delivery concerns, substance
exposed, preterm, other.
b) Developmental milestones/stages did they meet the milestones within reasonable time - none,
fine/gross motor, speech/language, cognitive, social/emotional, self help/coping, other.
E. Medical/Health screening
a) Medical health How will medical health concerns not impact services (if at all).
b) Psychiatric needs indicated, not indicated.
III. Summary
A. Service Priorities and potential goal areas.
a. What the client chooses to address in services and areas of moderate to severe impairment that they
do not choose to address and why (according to the client).
B. Barriers to Treatment an Special accommodations
a. Barriers and how they will be addressed.
b. Other needs requested none, gender, nutritional, other, language, age, allergies, transportation, age,
allergies, transportation, cultural, Stabenow law.
c. Learning needs affecting services none, describe.
C. Identify Strengths and Natural Supports and how they will be utilized in service priorities.
D. Recommendations (Include scope, intensity, duration and frequency of service to be provided or
recommended.)
E. Stage of Change- Pre-contemplation, Contemplation, Preparation, Action , Maintenance
a. Support your stance
Dont just use the descriptor from above, also put in pertinent information to use as evidence of your
assessment.

Reported
Identified
Expressed
Agreed
Stated
Acknowledged
Recognized
Gave Details
Conveyed

Words to Use
Disclosed
Explored
Revealed
Informed
Shared
Communicated
Clarified
Mentioned
Portrayed

Mentioned
Noted
Inferred
Relayed
Discussed
Voiced
Mentioned
Explained
According to

Words Not to Use

Thought
Felt
Told
Implied
Believes (ed)

Student:
Client Name

SW316 Section:
Case Number

Date Completed

Program

I. Presenting Problems/Concerns (Age, gender and ethnicity of client, reason for referral, referral source,
client/family perception of needs, etc.).
II. Summary of Clinical Screening and Assessment Results (Significant results of screening and assessment
information; reasons why areas of moderate to severe impact will not be addressed.)
A. Emotional/Behavioral Health and Mental Status

B. Addictions (Including the relationship between addictive behaviors and history of emotional, behavioral,
legal, and social consequences.)

C. Social Screening

D. Developmental Screening

E. Medical/Health Screening
III. Summary
A. Service Priorities (Discuss priorities to be addressed in services.)

B. Identify Barriers to Treatment, Special Accommodations needed, and how they will be addressed.

C. Identify Strengths and Natural Supports and how they will be utilized in service priorities.

D. Recommendations (Include scope, intensity, duration and frequency of service to be provided or

recommended.)
E. Stage of Change (Pre-contemplation, Contemplation, Preparation, Action, Maintenance )

Staff Signature/Credentials

Supervisor Signature/Credentials (if required)

Date

Date